Treating H. pylori

By Amanda Meeker, PharmD
and Cory Bradley, Pharm D


CareOregon frequently gets asked which regimens are covered for Helicobactor pylori (H. pylori). Due to the surprisingly high cost of varying regimens, not all are covered by CareOregon.   

H. pylori is very common and does not cause symptoms in a majority of affected individuals. Treatment is generally supported for all patients with a positive test, however the critical issue is deciding when to be tested.

When and how to test

  • If a patient has active or past peptic ulcer disease (PUD), gastric cancer, MALT lymphoma, or chronic NSAID therapy
  • Typically, symptoms of GERD do not require testing nor do asymptomatic patients
  • Use a stool antigen or urea breath test when diagnosing H. pylori. Avoid blood tests as they can have a high false positive rate


  • Preferred First-Line: Clarithromycin Quadruple therapy: omeprazole or pantoprazole BID, clarithromycin 500 mg, amoxicillin 1 g, and metronidazole 500 mg TID x 14 days
  • Alternative: Clarithromycin triple therapy: omeprazole or pantoprazole BID, clarithromycin 500 mg, and amoxicillin 1 g OR metronidazole 500 mg TID x 14 days
    • American College of Gastroenterology recommendation limited to patients with no prior history of macrolide exposure who reside in areas where clarithromycin resistance is known to be low.
  • Salvage Therapy: Levofloxacin triple therapy: Levofloxacin 500 mg, amoxicillin 1 g BID, and omeprazole or pantoprazole BID x 10-14 days

ACG Guidelines also support the use of other regimens not listed above, including bismuth quadruple therapy (with tetracycline) and LOAD (levofloxacin, omeprazole, nitazoxanide, doxycycline). However, these regimens are not covered due to their higher cost. If formulary options have failed or cannot be used, a formulary exception request can be submitted for review.

Reference: ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. American Journal of Gastroenterology. February 2017. Volume 112, Issue 2. Pg 212-239.